FINAL EXIT: This doctor sees death daily – but should he help suffering patients end their lives?

She was 48 years old, with curly blonde hair and no signs of the physical wasting away that so often occurs with advanced cancer. But her bowel was completely blocked from a rare and aggressive form of bladder cancer. She had uncontrollable vomiting and excruciating abdominal pain.

Dr. Manuel “Manny” Borod realized death was near, and that she was suffering. He knew she had to make a decision.

She was awake and lucid when, with her full consent, he injected her with a drug normally used to make surgery patients unconscious. She would sleep until she died – in her case, almost a week.

Borod hugged her tightly before he started the infusion. Then he walked alone to his office, closed the door behind him and cried.

“It was hard,” says Borod, head of the division of supportive and palliative care programs at Montreal’s McGill University. “We all said goodbye to her. It was very difficult for the entire team.”

Patient Lynne Cohen with Dr. Manuel Borod at the Montreal General Hospital in Montreal, on Thursday November 14, 2013.

Now, as his province sits poised to legalize doctor-hastened death, Borod raises a blunt question: Would euthanasia, a lethal injection that would have abruptly stopped her breathing and her heart – a step far more aggressive than the “palliative sedation therapy” he had administered – have been more humane?

If Quebec’s Bill 52 passes, Borod will be among the very few doctors asked to put to death patients who decide life is no longer worth living. It’s a notion he has rejected in the past as unnecessary and unwise, but which he now must confront, and which other doctors across the country may also one day face as Canadians debate end-of-life issues.

Borod, a mentor who has taught his colleagues how to “see” dying patients, how to search for the humanity in everything they do, struggles with how he will deal with a request for a doctor-hastened death if it becomes legal.

His own hospital has begun to grapple with the sheer practicalities of implementing Bill 52, Quebec’s proposed “medical aid in dying” legislation, with every expectation that it will soon become law. Who would administer the lethal injections? Where in the hospital would patients be euthanized?

“I don’t know what I would do,” he says. “I would probably feel that it would be part of my responsibility to be with the patient. But would I want to do it?”

Borod, one of Canada’s top palliative care doctors, worries that legalized euthanasia would make terminally ill patients even more frightened to see him than they are now.

He worries that too many people deemed “in an advanced state of irreversible decline” would be put to a premature death, since doctors are often poor at predicting survival times.

And he says people have options other than euthanasia to help make death, when it comes, peaceful and pain-free.

Postmedia News recently spent two days with Borod as he visited terminally ill patients and shared his thoughts about the role society now is asking him to play in granting sick people the freedom to choose precisely when, and how, they die.

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It is a mid-morning at the Montreal General Hospital. Borod, 62, is reviewing the morning’s patient roster with a nurse. He has blue eyes and grey hair; he smiles easily, and often.

Borod oversees a program inspired by palliative care pioneer Balfour Mount. Mount opened the first palliative care program of its kind in Canada at Montreal’s Royal Victoria Hospital in 1975. The goal: to ease the physical and psychological suffering of the dying. Mount’s mission lives on at the McGill University Health Centre’s palliative care programs, which include a day hospital and other outpatient services, as well as an in-patient unit with 15 private rooms that admits 300 terminally ill patients annually.

Dr. Manuel Borod, Director of the Division of Supportive and Palliative Care Programs at the McGill University Health Centre (MUHC) at the Montreal General Hospital in Montreal, on Wednesday November 13, 2013.

The day we visit the ward, every bed is full. Most patients are dying from cancer. In one room, a man lies motionless with his eyes closed, the white sheet pulled up to his chin. His face is grey and waxy; his jaw is slack. A massage therapist gently rubs his temples. In another room, a nurse carefully helps a woman move from her wheelchair to bed. The woman takes one step, then bends over suddenly, holding on to the edge of the mattress. Her shoulders heave with the effort of breathing.

Those who work closely with him describe Borod as uniquely calming, a doctor who uses extraordinary tact, compassion and honesty when delivering bad news.

His approach is simple: Find out how much the patient knows about his or her pending death. Find out how much he or she wants to know. See patients as the people they were before disease wore out their bodies.

“Many of my colleagues would feel that they can’t do this.” -Borod

When his father, Sam, an original member of the 1st Special Service Force, an elite Second World War U.S.-Canadian commando unit known as the “Devil’s Brigade,” was dying from dementia, Borod taped pictures of his father in uniform on the wall above his hospital bed, as if to say to the nurses and doctors: THAT’S who he was.

On this morning, Borod is seeing patients in the palliative care day hospital. He calls up the chart of his first patient on his computer screen: Lynne Cohen, an internationally renowned photographer diagnosed nearly three years ago with stage IV lung cancer that spread to her brain.

The prognosis was six months but “my shelf life has been extended,” the 69-year-old says.

Cohen’s voice is halting and choppy from the radiation, the veins in her arms badly damaged by chemotherapy. Her husband, Andrew Lugg, is seated nearby. Cohen tells Borod she is feeling “lousy” from the chemo and the nausea; she’s having more trouble with her speech. She hasn’t taken a photograph in two months.

She sometimes thinks of “pulling the plug,” she says, meaning she would stop all treatments. “You realize that, at any point you can stop treatment?” Borod asks her. She worries about what the end will be like, but tells Borod: “I feel confident with you in the background.”

She supports Bill 52 and the decriminalization of euthanasia and doctor-assisted suicide. She is more circumspect when asked whether she would seek such a death for herself. If she were suffering or in pain, “I would consider it.” But she worries about not experiencing “the exit,” the final moments of life.

Patient Lynne Cohen with Dr. Manuel Borod at the Montreal General Hospital in Montreal, on Thursday November 14, 2013.

If she had asked for euthanasia when she was first diagnosed, and if Bill 52 were then law, she would have satisfied all the legal criteria for assisted death, Borod says later in the privacy of his office.

“And I think it would have been bad,” he adds. “I think she’s had a good quality of life. She worries. It’s clearly not the life she wanted, but I think she and her husband enjoy their life, still.”

When Cohen nears the end, “we have the tools that we need. We would sedate her if she was having trouble swallowing, if she was having trouble breathing — if she had so much existential distress that she didn’t want to live anymore,” Borod says. “We have that relationship: I know what she wants.”

Borod can legally sedate a patient even without Bill 52, and simply let that unconscious patient drift into death. Under Bill 52, he would be empowered — at the patient’s request — to make death happen. The ethical chasm between the two methods of death troubles him deeply.

He leans back in his chair and looks out the window.

‘I will help you through the dying process.’

There is a water bowl beneath his desk for his golden retriever, Gracie. His wife, Diana, takes Gracie to the hospital once a week to visit the palliative patients. Another retriever, Roxie – Borod’s “soul dog” – died two years ago. After the hardest days, Borod would lie in bed and Roxie would climb up next to him and rest her head on his chest. The sensation, he says, “felt like a healing.”

Borod says his profound unease with Bill 52 isn’t a “religious thing,” or a right-to-life issue. Rather, the proposed criteria for Bill 52 – which would permit patients of legal age who were mentally competent, and suffering an incurable serious illness with “constant and unbearable physical or psychological pain,” to seek doctor-hastened death – are too broad for his comfort. Could they, for instance, apply to a concert violinist who had a stroke that paralyzed one arm, and who decided this was so unbearable he wanted to end it all?

“I know that many of my colleagues would feel that they can’t do this,” Borod says.

People often don’t understand that they already have the right to refuse medical treatment, or to demand that treatment, once started, be stopped. What’s driving the demand for euthanasia is largely fear, Borod says – of suffering, or of being subject to an unstoppable whirlwind of aggressive treatments, strapped to a bed, tied to machines and monitors and unaware of what is happening.

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If he could choose his own death, Borod says he would go on the 18th hole, after someone said: “Nice putt.”

Borod believes in the role humour plays in palliative care. It helps ease tension and anxiety; it helps him communicate with his patients. He once wrote that too many staff, and families, walk into a patient’s room as if they were already attending a funeral.

“I understand that when I meet somebody they’re not going to be my friend forever, that our time is going to be limited,” Borod says. “But I enter a contract with them: ‘I will help you through the dying process.’ ”

He estimates he has helped 2,000 to 3,000 people through their final life journey. Yet for every rare request for “hastened” death, he gets 100 demands to prolong life even when hope is gone.

Borod recently treated a 72-year-old woman with ovarian cancer. She was dying, but her daughter was insisting that CPR and every other possible measure be used to try to save her should her heart stop.

He explained the futility and violence of CPR. He explained that even in the remote event the woman was to survive, she would be left with brain damage. After an hour of discussion, the family agreed to place a DNR order — “do not resuscitate” — in her chart.

Some people are in denial about their prognosis, Borod says. But it is especially hard when the entire family is in denial as well, because it can be impossible for them to make crucial decisions about what they would and would not accept at the end of a loved one’s life.

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One patient Borod sees on this day was diagnosed with head and neck cancer two years ago. There is a mass growing in the left side of his mouth. The surgeons had to cut into the lower part of his face, from ear to ear, to remove part of his tongue, then, later, his jaw. He is badly disfigured and there is a feeding tube in his stomach.

He and his wife are waiting to hear whether doctors will offer more radiation.

“You would want more radiation at this point, if you feel it would prolong your life?” Borod gently asks him.

“I don’t want to die. Not yet,” the man answers.

He’s depressed and isn’t sleeping at night, he tells Borod. He wants to know how much time he has left. Borod tells him that he hopes it will be months. “But things can change. Your situation is very fragile.”

In his office later, Borod asks: “If he gets more radiation, will it do more harm than good? Will he live long enough for the radiation to help him?”

In 2006, Borod’s mother, Layah, was admitted to intensive care at the General, Borod’s own hospital. She was 82 and in respiratory distress after failed heart surgery. The doctors connected her to a machine that pushed air and oxygen into her lungs. It was clear that she would never again be able to breathe on her own.

He recounts the family discussion: “We finally all agree that she’s not going to survive so we withdraw the oxygen. Three months later, my dad says to me, ‘I think we killed mum when we stopped her oxygen.’

“I told him, ‘mom was dying, we didn’t want to prolong her dying,’ that she never would have recovered, and that in no way did we kill her,” Borod says. “What we did was withdraw treatment.”

He pauses. “I do this” – meaning his daily work with the dying and their families – “and I still missed the boat a bit in trying to get him to understand what we were doing.

“None of this is perfect, for anybody. We don’t want to suffer, or our family to suffer.”

Borod has two grown children. His son is a lawyer in New York, his daughter a high school teacher in Montreal. “ We’re hopeful that we’ll go peacefully. But why is euthanasia the answer?”

“I can’t say that I would never – under any circumstance – consider hastening death. That is too extreme,” he says. “But, I just don’t see the need for it.”

In the hospital rooms outside his cramped office, two more patients wait: a 67-year-old woman with cancer of the sinus who has already lost her right eye; and an 80-year-old retired lawyer with advanced cancer of the bone and soft tissue. His doctors are offering more chemotherapy.

“I feel very strongly about not forcing treatment, about letting people die and not getting in the way,” Borod says as he moves toward the corridor.

“But we don’t have to kill them.”

skirkey@postmedia.com

Twitter.com/sharon_kirkey

SOME QUESTIONS AND ANSWERS ABOUT ASSISTED DYING

Quebec’s proposed euthanasia law, Bill 52, is undergoing a detailed review by a parliamentary committee of Quebec’s National Assembly. The bill could pass early in 2014, which would make Quebec the first province to legalize mercy killings.

Q. What is Bill 52?

Bill 52, “An act respecting end-of-life care,” would permit “medical aid in dying” for patients who meet the following criteria:

–be of full (legal) age and capable of giving consent;

–suffer from an incurable serious illness;

–suffer from an advanced state of “irreversible decline in capability” and

–suffer from constant and unbearable physical or psychological pain “which cannot be relieved in a manner the person deems tolerable.”

Q. How would someone’s life be ended?

The bill doesn’t spell out what form “medical aid in dying” would take, only that, once the criteria have been met, the doctor “must administer such aid personally” and take care of the patient until death. Most doctors believe death would be via lethal injection.

Q. What does Canada’s Criminal Code say about euthanasia and assisted suicide?

Section 14 of the code states: “No person is entitled to consent to have death inflicted on him.” A doctor who gives a patient a lethal injection at his or her request would be criminally liable.

Section 241 of the code deems it an offence to counsel, aid or abet a person to commit suicide, a crime punishable by up to 14 years in prison.

Q. So how would Bill 52 avoid breaking the law under the Criminal Code?

It does so by declaring “medical aid in dying” – that is, euthanasia – a medical act, and therefore an act under provincial, not federal, jurisdiction.

Q. Are doctors willing to administer a lethal injection?

A survey conducted in May, 2013 by Leger Marketing for the Quebec Medical Association of 1,201 French- and English-speaking doctors found 66 per cent supported “medical aid in dying as appropriate end-of-life care.” Among the doctors most likely to receive a request for euthanasia, 41 per cent said they would agree to a patient’s request for a quick death if the person met eligibility criteria. The rest were divided: 30 per cent said they would refuse, and 30 per cent said they were not sure.

AN END-OF-LIFE GLOSSARY

Euthanasia: Knowingly and intentionally performing an act that is explicitly intended to end the life of a person with an incurable illness. The act is undertaken with empathy and compassion and without personal gain.

Physician-assisted suicide: Knowingly and intentionally providing a person with the knowledge or means, or both, required to commit suicide, including counselling about lethal doses of drugs, prescribing such lethal doses or supplying the drugs.

Medical aid in dying: A generic term encompassing both euthanasia and physician-assisted suicide.

Palliative sedation therapy: The use of pharmacological agents to reduce consciousness. Reserved for the treatment of “intolerable” or uncontrollable symptoms in patients with an advanced, progressive illness. Continuous palliative sedation therapy is the use of ongoing sedation continued until the patient’s death.

Advance directives: Verbal or written instructions that the patient has provided about the kind of care they want or do not want in the event they cannot speak for themselves.

Life support: Medical or surgical procedures such as tube feeding, mechanical ventilation, kidney dialysis and CPR. All use artificial means to restore or prolong life. Without them, the person would die.

Comfort measures: Treatments to keep patients comfortable (such as pain control) but not to keep people artificially alive or cure any illness.

Palliative care: Care for people living with a life-limiting illness that is usually at an advanced stage. Care is aimed at improving the quality of living and dying. It includes pain and symptom control, as well as psychological, emotional, social and spiritual support.

The right to refuse medical treatment: The right of a competent adult to refuse unwanted medical treatment or to demand that treatment, once begun, be stopped.

(Sources: Canadian Medical Association; Canadian Researchers at the End of Life Network; The Royal Society of Canada Expert Panel on End-of-Life Decision Making; Canadian Hospice Palliative Care Association.)

WHAT THEY’VE SAID ABOUT LEGALIZING EUTHANASIA

“I can simply say it isn’t the intention of our government to propose this type of change to the law. I think it’s important to resist the idea of giving the power to kill. I understand the reasons some might want to propose this. If there is a proposal like this in the House of Commons — a moral question — I would always allow my members a free vote.” — Prime Minister Stephen Harper during a French-language leaders debate, Jan. 10, 2006.

“I know that there are a variety of opinions and deeply held moral opinions about this, but we are not going there. We are not going to open up a debate.”— Federal Justice Minister Peter MacKay, Sept. 26, 2013.

“Then there is the sensation of drowning in your own phlegm. I’ve experienced it and it’s a form of torture. You can’t sleep and you become sleep deprived – it’s a living nightmare … I think those people (the terminally ill) should have the opportunity to ask for help to close life’s circles.”— Conservative MP Steven Fletcher, a quadriplegic, Sept. 25, 2103.

“This legislation is intended for people at the end of their life to die with autonomy, and dignity.”— Quebec Social Services Minister Veronique Hivon, the driving force behind Bill 52, “An Act Concerning End-of-life Care,” introducing the bill in the National Assembly, June 12, 2013.

“This is a national discussion that every one of us, as citizens of this country, is going to have to think about. It’s about human beings deciding what kinds of choices they believe that they should have.” — Ontario Premier Kathleen Wynne, Sept. 26, 2013.

“Killing is not care. Killing a patient, even upon his or her request, is grave ethical misconduct in a so-called civilized society.”— The Physicians’ Alliance for Total Refusal of Euthanasia, an alliance of Quebec doctors who oppose legalization of euthanasia and assisted suicide, Sept. 24, 2013.

“When I realized I had a disease that was terminal and there was no going back, I looked at alternatives into making your own destination, deciding on your own outcome, deciding when you’re going to die. What surprised me the most was the objection to it, the inability to do it in Canada …. I wish (opponents to euthanasia) could live in my body for 24 hours. I’m just frustrated at not being able to have control of my own life, not being able to make the decision for myself when enough is enough.” — Infectious disease specialist Dr. Donald Low in a video taken eight days before his Sept. 18, 2103 death, at age 68, from a brain stem tumour.

“I think what we’re seeing is that society is saying, ‘Enough of us are going through this and we want to have a frank discussion.’ The Canadian Medical Association is not shying way from this issue. But at the end of the day, society is going to lead the way. It’s not going to be physicians.”— Canadian Medical Association president Dr. Louis Hugo Francescutti, Aug. 17, 2013.

“You have a large role to play. You are the gatekeepers. You will make the determination in many, many cases as to how your patient will die.”– Former Liberal senator Sharon Carstairs, speaking to delegates at the CMA’s annual general council meeting in Calgary, Aug. 19, 2013.

“Medical aid in dying is a medical service that’s within the continuity of life care. It’s aimed at helping the patient die under strict conditions at the patient’s request. It’s not legalizing euthanasia for us — it’s something new. It’s a way to care for the patent at the end of his life.”– Dr. Laurent Marcoux, president of the Quebec Medical Association, Aug. 19, 2013.

“Many people don’t realize there is already the complete right to say no to any treatment, and to stop any treatment that they don’t want to have …. I would posit that we need to develop better care of the elderly, rather than just killing them off.”— Palliative care pioneer Dr. Balfour Mount, emeritus professor of palliative medicine at McGill University In Montreal, Sept. 20, 2013. Mount retired in 2007, after surviving esophageal cancer and a heart attack.
– Compiled by Sharon Kirkey, Postmedia News.